Medetomidine: New hidden danger in opioid withdrawal for inmates

When Lillian entered a rural Pennsylvania jail, she was overwhelmed by nausea. Even as she showered and changed into her jail attire, “brain zaps” disrupted her balance. “The corrections officer had to catch me several times to prevent me from collapsing,” Lillian shared.

She was experiencing withdrawal from fentanyl tainted with medetomidine, a strong tranquilizer that began infiltrating the illegal opioid supply two years ago. Medetomidine withdrawal is severe and complex, often beginning within hours of the last dose, leaving many institutions unprepared to manage it. This treatment gap is particularly evident in prisons.

Lillian was enduring a withdrawal that could lead to strokes or heart attacks. She reported only receiving ibuprofen and Pepto-Bismol for relief. “It was a nightmare,” said Lillian, who preferred to remain anonymous due to the stigma surrounding drug use in her community. “I’m amazed I survived.”

Jails have a troubled history of managing inmates who undergo withdrawal after losing access to opioids or other substances. Limited resources, staffing shortages, and a lack of protocols contribute to deaths from opioid withdrawal, which have resulted in lawsuits nationwide. These deaths are preventable with FDA-approved medications for opioid withdrawal.

Now, jails face the additional challenge of handling medetomidine withdrawal, necessitating complex treatments involving oral and intravenous medications, some of which are restricted to intensive care settings. This issue is on the rise: The CDC reported in April that medetomidine, or “dex,” is present in drug samples from all 20 sentinel sites, most prevalent in the Northeast and least in the West.

Pittsburgh on leading edge

The readiness of jails to address medetomidine withdrawal often depends on political and financial factors. In Pittsburgh, near the rural jail where Lillian was held, Chris, who withheld his last name, faced the same withdrawal in Allegheny County Jail. He was given Ativan and phenobarbital, which sometimes ease symptoms. “I was thankful because I didn’t expect the county jail to provide such care,” Chris said. “They let me rest on a comfortable bed in the medical processing area, which, in jail, is a rare luxury. I lay down, and the next thing I knew, I was waking up in the hospital days later.”

It was then he learned that medetomidine withdrawal had led to a heart attack.

Pittsburgh, significantly affected by medetomidine, is also better equipped to tackle the problem. Elizabeth Ferro, Allegheny County Jail’s director of addiction medicine, collaborated with Michael Lynch, a University of Pittsburgh Medical Center physician researching medetomidine withdrawal treatments. Ferro noticed severe opioid withdrawal symptoms in inmates and reached out to Lynch, who invited her to his webinars on the subject.

Jails with established opioid withdrawal and use disorder treatments are better positioned to manage medetomidine withdrawal. According to Ferro, treating both conditions is crucial as medetomidine withdrawal often accompanies opioid use disorder. Thanks to efforts by Bethany Hallam, an Allegheny County Council member who has personally experienced withdrawal, and Stuart Fisk, a nurse practitioner who improved access to medication-assisted treatment for opioid use disorder (MOUD) within the jail, the Allegheny County Jail has expanded its treatment programs.

Fisk, now part of a trust overseeing opioid settlement funds distribution in Allegheny County, advocates for using some of those funds for addiction medications. Federal laws prohibit Medicaid from covering jail medications, so expenses fall on the county budget, making expansions contentious.

Hallam has countered arguments against providing withdrawal medications in jail due to costs or diversion risks. Buprenorphine and methadone, which treat both opioid use disorder and withdrawal, were initially limited to pregnant women when Hallam was incarcerated in 2017. She pushed for the jail to offer Sublocade, an injectable form, and over the last two years, more options have become available. A National Commission on Correctional Health Care position paper stresses the importance of offering a range of FDA-approved medications for opioid use disorder in jails.

Despite Pittsburgh’s preparedness, not all cases are resolved. Chris, after his interview, was re-arrested while in withdrawal and suffered another heart attack, leading to a five-day coma and eventually his death earlier this month.

Difficult to detect

With medetomidine spreading nationwide, jails unprepared for opioid withdrawal might face severe cases. Ferro wishes for a collaborative effort among Pennsylvania jails to address medetomidine-related health issues. She received only one inquiry about severe withdrawal symptoms from a rural jail, offering to help identify the issue as medetomidine withdrawal, but heard nothing back.

Kevin Fiscella, a University of Rochester physician who developed withdrawal protocols for U.S. jails, suggests many jails should emulate Allegheny County Jail by sending severe withdrawal cases to hospitals. He highlights that many jails already stock clonidine, a blood pressure medication crucial for treating medetomidine withdrawal, though higher doses may be necessary.

However, jails must first recognize medetomidine withdrawal. Lynch noted its difficulty to identify, recalling patients in severe distress since fall 2024. They exhibited symptoms like shakiness, sweating, nausea, and elevated heart rates and blood pressure, resembling but more intense and rapid than typical opioid withdrawal.

Standard urine toxicology tests don’t detect medetomidine. Instead, emergency physicians confirm its presence by noting continued symptoms despite treatment. Fiscella advises jails to begin treatment aggressively, using medications like buprenorphine to quickly determine if medetomidine is involved.

Many jails lack buprenorphine or other opioid use disorder medications. In 2022, the Department of Justice’s Civil Rights Division issued guidance stating that denying medications to inmates with prescriptions violates the Americans with Disabilities Act. However, this doesn’t extend to those without existing prescriptions, often experiencing severe withdrawal in jail. Nonetheless, the guidance implies jails should provide MOUDs to some prisoners. A national jail survey post-guidance found fewer than half offered any MOUD.

The availability of such medications in jail can enhance health outcomes and reduce mortality during and after incarceration. A randomized controlled trial showed that jails implementing NCCHC accreditation standards, requiring MOUDs, saw significant mortality reductions. However, jail accreditation is voluntary, noted Marcella Alsan, a Harvard physician and economist. “Funding this care is challenging as Medicaid and health insurance cannot legally cover jail health care, putting sheriffs and counties in difficult positions,” Alsan said.

The National Sheriffs’ Association opposed the Federal Medicaid Inmate Exclusion Policy, arguing it denies presumed innocent individuals their federal benefits without due process, violating constitutional rights.

“Some sheriffs prioritize this issue, while others have many concerns,” Fiscella said. The severe symptoms of medetomidine withdrawal, however, might prompt jails to take opioid use disorder treatment more seriously.

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